Any residual patient complaints should be investigated at this stage. Proactive dry eye management encouraged.
An inorganic material is not as likely to create an issue and often the risk of flap relift and irrigation outweighs the benefit. When in doubt, refer to the centre.
You may not be able to judge this if it is early post operatively, as the edema may confound the issue. It is appropriate to monitor for a week before triaging to the surgeon unless there is inflammation- in which case prompt referral is necessary.
Any diffuse lamellar keratitis/inflammation should be urgently referred to the surgery centre given the risk of progression. A flap relift and irrigation will be considered.
Diffuse Lamellar Keratitis: looks more "fluffy" in appearance, whitish precipitates, and can congeal into waves of sand appearance. Usually extends from the flap edge towards the centre. Located in the interface.
Superficial Punctate Keratitis: Located on the epithelium. Unstained, DLK and SPK look similar and can be hard to distinguish the depth. Fluorescein staining will be the key to differentiating. If it stains, it isn't DLK.
White granular cells in the periphery, centre cornea is clear. Most common on Day 1 post op. Would be appropriate to treat with Pred Forte gtts hourly and follow up the next day before referring.
White granular cells in the periphery and involves the visual axis (central). Most common on Day 2-3 post op and is a result of migration of inflammatory cells from periphery inwards. Recommend referral.
White granular cells centrally, more dense. May have some peripheral clearing. Visual acuity may decline a line or two. Patient may complain of hazy vision. **Needs emergent triage to surgery centre
White granular cells centrally, more dense. Stromal melting and "mud cracks" (indicating central toxic keratopathy), bullae formation, significant reduction in visual acuity, and hyperopic shift. **Needs emergent triage to surgery centre
If we relift the flap and irrigate the DLK, there may be a bandage contact lens which should be removed Day 1. Vision may remain blurry until the BCL is removed.
When in doubt, refer. You never want to delay surgical intervention in these cases. If any central involvement, refer urgently.
Refractile debris: Pinpoint discrete particles which can be scattered diffusely with clear space in between the particles. Can be shiny especially if microkeratome was used. (Note: Clarity Laser Vision does not use microkeratome.)
Diffuse Lamellar Keratitis: looks more "fluffy" in appearance, whitish precipitates, and can congeal into waves of sand appearance. Usually extends from the flap edge towards the centre.
You may not be able to judge this if it is early post operatively, as the edema may confound the issue. It is appropriate to monitor for a week before triaging to the surgeon unless the VA is significantly reduced- in which case prompt referral is recommended.
Refractile debris is usually an incidental finding and is self limiting and is not likely to impact outcome. However, if you see surrounding inflammation, refer to the surgery centre for assessment.
If we relift the flap and irrigate the debris, there may be a bandage contact lens which should be removed after a few days. Vision may remain blurry until the BCL is removed.
â—¦ Discrete pinpoint particulates, sometimes shiny
â—¦ Usually do not require intervention
When referring for enhancement, please either include last 3 refractions, or a comment on stability of refraction
Chamber should be well formed with no reaction. If any issues, likely unrelated to cataract surgery and should be investigated as appropriate.
Any uveitis at this stage of healing is likely unrelated to surgery. Need a second opinion, or just want someone else to manage a uveitis? Send to me and I’ll manage the acute condition, while you remain the primary eyecare provider!
If lens is too tight as evidenced by excessive conjunctival conjestion and excessive pain, consider removing and replacing the BCL
***Ideally done undilated. Patient may arrive still dilated in the first few days after surgery, which will affect your assessment
The fenestrated ports in the EVO ICL design have significantly lowered the risk of cataract formation. If vault is 0.5 or less, consider sending to the surgery centre for more exact measurement/monitoring. If vault is greater than 2, watch closely for pupil block.
You can also measure vault in microns on some OCTs and Pentacam
Flap edema is normal at this stage- you will see a slight "orange peel" appearance but the iris structures should remain visible through the cornea.
When referring for enhancement, please either include last 3 refractions, or a comment on stability of refraction
The edema should be pretty much resolved- however if significant edema persists, now is the time to intervene. First, rule out Persistent Interface Fluid Syndrome. Click here to learn more.
The neural feedback loop for dry eye sensation is still impacted- rely on the clinical appearance more than symptomology.
Our commitment is to the long-term health of the eye after surgery. We monitor subtle changes with advanced testing specific to the surgery performed. We focus only on the surgical outcome and rely on you, the primary care optometrist, for the yearly eye health examination.
The neural feedback loop for dry eye sensation is still impacted- rely on the clinical appearance more than symptomology.
You may have noticed that the patient experience is quite different between the two clinics. Seema Eye Care is a very popular specialty clinic that sees a very high volume of patients, striving to help all those in need of our care. For this reason, it takes more time to process patients through the system. There is also an expected waiting time for surgery for AHS covered cataract surgeries, which is influenced by AHS policies and outside the control of Seema Eye Care centre. Clarity is designed to offer a higher touch, premium experience for our private pay Refractive clients. Clarity sees less volume, therefore can accommodate more timely referrals and appointments.
Patient looking down
Lift lens with forcep as they look back up
If BCL feels "stuck", irrigate the eye with BSS to "float" the lens loose then try again with forceps
With the femtosecond laser we can create very thin flaps which has many advantages including preserving corneal tissue and less dry eye. However these are delicate flaps that sometimes need the bandage contact lens overnight to encourage a smooth flap adherence in those first vulnerable 24 hours. If the flap looks smooth, you can remove it at the Day 1 visit.
Patients with these conditions should absolutely not consider refractive surgery:
We evaluate each individual as a whole and carefully weigh the risks/benefits of surgery. If refractive surgery is not in their best interest, we won't do the surgery. If you are unsure, send them our way- be sure to include any questions/concerns you may have!
Meibum debris: looks like discrete tiny oil droplets fairly localized (you can see distinct edge to the focal area of debris). Can look like an isolated "island" in the middle of cornea (does not always extend from flap edge)
Epithelial ingrowth: amoeba-like blisters (can be clear or opaque), larger than meibum debris, more irregular shape than meibum debris. Usually extends from the flap edge towards the centre although rarely it can be an "island" of cells.
Epithelial ingrowth can sometimes cause a mixed astigmatism refraction- but remember, one can have a similar refraction within the first 1 month of surgery normally. It is only relevant later post operatively if you have documented a true refractive shift over time. Epithelial ingrowth may or not affect vision.
Clinically significant epithelial ingrowth can cause a persistent FB sensation that is not relieved with artificial tears. If this is the case, it is appropriate to refer to the surgery centre for evaluation.
If the epithelial ingrowth is extending more than 1 mm into the cornea, then it is appropriate to refer to the surgery centre for evaluation.
If you are monitoring and the cells change from clear blister-like appearance to more opaque plaque-like appearance, they are less likely to progress.
If we relift the flap and irrigate the debris, there may be a bandage contact lens which should be removed after a few days. Vision may remain blurry until the BCL is removed.
Any foreign object between the flap and the stroma
May or may not require intervention
flap should be smooth
classify into hairline, microstriaie, or macrostriaie
flap should be smooth
usually associated with trauma
any flap shift should be emergently referred to the surgery centre (same day).
Residual edema is not always requiring intervention-older patients or those with diabetes may simply take longer to heal.
First, do triage assessment (see below)
Combigan bid x 4 weeks (or other
glaucoma drop as appropriate)
monitor monthly until either resolves or obvious that it will remain
1. persistent reduced vision
2. to assess endothelial health
3. to confirm diagnosis
Council on good sleep
habits, hydration, eye
lubrication, and managing
stress levels
This is a rare condition but anytime you feel the vision isn't improving as it should, or the edema is persisting, or there is a hazy appearance to the cornea that isn't resolving, one should consider this as a differential.
It can look similar to DLK and can mislead the clinician to prescribe steroids. The onset of the condition is key- IFS usually takes > 1 week to present clinically whereas DLK usually presents in the first week.
Usually enough to obscure the iris structure Usually visual acuity is affected
Occasionally can be seen on slit lamp using 40x mag and optic section beam
Best shown on corneal OCT where you see a black pocket of fluid
You can't judge this the regular way- any instrument testing central cornea will give a false low measurement. If you suspect this syndrome, take a Goldman IOP with the patient looking up (the IOP prism head should mostly be on the inferior portion of the cornea, with as little flap touch as possible). This will give a more accurate assessment of IOP especially if it is several points higher than the central measurement
Check for endothelial decompensation
Check for uveitis and treat accordingly
It's important to differential from DLK because steroids can worsen interface fluid syndrome. There is a risk of optic nerve damage from prolonged IOP rise. So be careful to make sure your IOP measurement is accurate!
Red blood cells do not impact vision and will likely resorb with time. However, they can increase the risk of DLK formation, so it is prudent to monitor more closely in the first few days after surgery. Note: in this picture there is DLK surrounding the red blood cells , but no central involvement, so increasing steroid dosage and close monitoring would be appropriate.
Hairline: very fine, not visible on retroillumination, not visually significant. These are common with extreme starting prescriptions and no intervention is necessary
Microstriaie: fine, visible on retroillumination, may or may not be visually significant. If they bisect visual axis or are multiple then they are likely to impact vision. If VA is reduced or if you are unsure, refer for assessment.
Macrostriaie: large, visible on retroillumination, almost always visually significant. Refer for assessment as soon as possible. Likely requires a relift.
You may not be able to judge this if it is early post operatively, as the edema may confound the issue. It is appropriate to monitor for a week before triaging to the surgeon unless they are macrostriaie or the VA is significantly reduced- in which case prompt referral is necessary.
The flap edges should line up with the original cut. If there is any stromal exposure, urgent referral is necessary.
After a flap relift there may be a bandage contact lens which should be removed after a few days. Vision may remain blurry until the BCL is removed.
Meibum debris: looks like discrete tiny oil droplets fairly localized (you can see distinct edge to the focal area of debris). Can look like an isolated "island" in the middle of cornea (does not always extend from flap edge)
Diffuse Lamellar Keratitis: looks more "fluffy" in appearance, whitish precipitates, and can congeal into waves of sand appearance. Usually extends from the flap edge towards the centre.
You may not be able to judge this if it is early post operatively, as the edema may confound the issue. It is appropriate to monitor for a week before triaging to the surgeon unless they the VA is significantly reduced- in which case prompt referral is recommended.
Meibum debris is usually self limiting and unless it is in the visual axis, is not likely to impact outcome. However, if you see surrounding inflammation, refer to the surgery centre for assessment.
If we relift the flap and irrigate the debris, there may be a bandage contact lens which should be removed after a few days. Vision may remain blurry until the BCL is removed.
***looks like a rolled up carpet
- a small detachment can be observed
- a large detachment needs to be assessed by the surgeon
***both are required to notify the surgeon. It is imperative
to differentiate the two so you can implement timely
treatment correctly
Maassen JL, Folk JC: Endophthalmitis: 82-year-old male status post phacoemulsification in the left eye with acute decrease in vision. Eyerounds.org. December 5, 2005; Available from: http://www.EyeRounds.org/cases/45- Endophthalmitis-After-Cataract-Surgery.htm.
Both require urgent attention by the surgery centrenotify the surgeon immediately. If you suspect endophthalmitis this is an emergency and every hour counts!
Monitoring regression requires patience...it can take up to 6 months for the refraction to stabilize after cornea surgery. Generally we refrain from enhancements until at least 6 months post operatively.
If the patient is NOT 20/happy, then we need to validate the patient concerns. The Snellen Visual Acuity and manifest refraction are faulty metrics for outcome at best. If you feel, despite all of your testing being within normal limits, that the patient is not happy with their outcome, send patient to the surgery centre for a consult. We will analyze in great detail the refraction (in 0.01D increments), aberrometry, and corneal healing pattern. We will do everything within our power to address the patient concerns.
It is recommended to wait a minimum of 3 months after surgery before performing a YAG capsulotomy to ensure a stable capsule/zonule system.
Some symptoms that would suggest considering a YAG are:
Send for YAG capsulotomy if patient is symptomatic and they present with one of the following in the posterior capsule:
Sometimes if a patient has an unwanted residual refractive error, we will perform a YAG capsulotomy prior to intervening with more invasive surgery to see if the IOL placement would be improved.
***looks like "lobes" of choroidal elevation in up to 4 quadrants
- differentiate from retinal detachment
- can have shallowing of the anterior chamber
- may have increased pain
- look for wound leak
- look for hypotony
- although some small choroidal effusions can be monitored for self resolution, it is best to notify the surgery centre, as this can potentially be a vision-threatening condition requiring surgical intervention
Contributor: Jesse Vislisel, MD
Photographer: Brice Critser, CRA
***injectable corticosteroid during cataract surgery - used in complex cataract cases to help reduce inflammation and visualize vitreous especially if there was trauma during surgery
Contributor: Eric Chin, MD
Photographer: Cindy Montague, CRA
Phimosis is a fibrotic metaplasia of the anterior capsule causing the anterior capsulotomy to "shrink" and create visual disturbances.
It is recommended to wait a minimum of 3 months after surgery before performing a YAG capsulotomy to ensure a stable capsule/zonule system. However if the phimosis is visually significant, can send sooner for surgeon to evaluate.
Contributor: Jesse Vislisel, MD
Photographer: Stefani Karakas, CRA
http://webeye.ophth.uiowa.edu/eyeforum/atlas/pages/capsular-phimosis/index.htm
**It is highly recommended that you have an IOP Emergency Kit at your office
Treat pupil block as an emergency. Always start IOP lowering medications (from your IOP kit) prior to sending the patient to Clarity Laser Vision immediately. Help us triage the patient appropriately by asking for Amera when you call the emergency line. She will ensure that one of the doctors will attend to the patient without delay.
Don't be myopic in the pursuit of perfection. If patient is 20/happy with their outcome then the risk of intervention, even glasses, outweighs the benefit. Remember, even a mild mixed astigmatism may be beneficial for some near benefit. It's not always about a perfect plano result. Happy patient= happy surgeon!
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